Hatfield Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care, medicines and staffing.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Accidents and incidents had been recorded on the electronic care plan system by staff, there was a process in place to produce a matrix using the information. However, there was no evidence the information had been analysed and used to learn lessons.

The registered manager had reviewed the information of each individual accident or incident and confirmed it had been recorded. There had been occasions when the registered manager had decided some incidents should not be recorded as incidents such when someone choked. There was no review recorded by the registered manager of what had happened and if there was any action which could be taken to reduce the risk of it happening again.

The accident matrix did not have clear information how often people fell, if there were any patterns such as place or time of day or any action taken. We could not be assured lessons were being learnt to keep people safe.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Before people moved into the service, they met with the management team to check staff could meet their needs. However, the records of these assessments were not always detailed, and people had been admitted to the service when it may not have been the most appropriate place for them. For example, people spoke to us about their experience of living at the service when they did not have a diagnosis of dementia. They spent all their time isolated in their room as they were not comfortable in the communal areas as they had not been able to make friends or have conversations.

When people had returned from hospital admissions, their care plans had not always been updated with relevant guidance, such as catheter care.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We reviewed incident records for May 2025 and identified 3 incidents which had not been recognised as potential safeguarding concerns. Previous safeguarding notifications received by CQC had been raised following requests by social services. Staff had recognised when incidents needed to be recorded. Staff had received training and were able to describe how they would recognise abuse and knew how to report it, including to external agencies. However, the registered manager had not fulfilled their role to report potential safeguarding concerns. Incidents had not been reported to the local safeguarding authority or CQC as required. The failure to report the incidents placed people at continued risk as investigations had not taken place to reduce the risk of them happening again.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff did not always follow guidance or understand how to keep people safe. Some people were at risk of choking and aspirating their diet and fluids, they had been assessed as requiring thickened fluids and pureed foods. Records showed people had been offered and eaten a normal diet, such as egg on toast, when they had not wanted pureed food. People requiring thickened fluids had been given ice lollies and ice cream, which change to thin fluids when melted.

When people were at risk of pressure damage to their skin and had a pressure relieving mattress to reduce the risk. However, people’s mattresses were not always set up correctly according to their weight. Some mattresses were set at double the person’s weight, placing people at risk of skin damage as the mattress would not be providing the appropriate support. There was no guidance for staff about what skin damage looked like and how often to support people to move to reduce the risk.

Some people had a catheter, to drain urine from their bladder. There was not always guidance in place for staff to support them and reduce the risk of infection, including when to change the drainage bag. Staff had not always recorded if people’s catheter bags had been changed.

There were risk assessments in place for various risks, but these were not person centred. For example, the same guidance was in place for all people living with diabetes. There was no information about how diabetes affected each person such as their normal blood sugar range and how they presented when they were unwell. There had been no consideration in the guidance about the diet diabetics should have such as low sugar.

When people were prescribed creams which were highly flammable, there was a risk assessment in place. However, there was no guidance, such as when to change bed linen and clothing to reduce the risk. Potential risks linked to people’s health conditions such as osteoporosis had not been identified. There was general information about the conditions but not how this affected people and the risks this presented.

Some risks had been identified but the guidance was incomplete. Some people were prescribed medicines which thinned their blood, there were general side effects listed, but there was no guidance about the action to take if the person sustained an injury.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The provider had a fire evacuation plan in place which described how people should be evacuated horizontally within the building and not use the lift, but it did not mention the stair lifts. There had been fire drills held at the same time during the day, however, drills had not been completed at night. The records showed not all care staff had been involved in the drills and domestic staff had not been involved at all. There had been an evaluation of the drills, it had been identified in August 2024, October 2024 and March 2025 there was confusion with the use of radios, there had been no action to address this.

During our onsite inspection, the fire alarm activated, it was a false alarm. During this alarm, we reviewed the evacuation route through the garden, where there was a locked gate. We asked staff what the code was to the key safe to access the key, they did not know the code and when we asked the registered manager, they were not sure. The registered manager eventually opened the key safe after a couple of attempts. Staff not knowing the code to the key safe placed people at risk if there was a fire.

We asked staff to describe how they would evacuate people in the event of an emergency. They described to us how they would evacuate people to outside the premises. They were unable to describe to us the horizontal evacuation process in the fire evacuation plan.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. There were not enough staff and their deployment was poor, to support people effectively. When we arrived onsite, there were people in the communal lounges who had been supported to get up by the night staff. We observed 2 senior care staff completing the medicines round. They were based in the dining room and took people’s individual medicines to them around the building. They did not complete the medicines until 11.30am, during this time they were unable to support people.

The remaining 4 staff were allocated to support people with personal care, the allocation sheet only had room for 18 people to be allocated, though there were 33 living at the service. Staff and the registered manager told us the others were supported by night staff. There was no contingency plan if night staff had not supported all the people allocated to them and limited people’s choice of when they received their support.

There were limited support staff, there was an activities co-ordinator but not at the weekend, there were no cleaning staff after 2pm and limited catering support in the evenings. The registered manager told us, ‘We have one full time cook and a tea / supper person 5 days a week, we also have a part time cook for 2 days a week, in addition to the servery person 7 days a week. In case of any sickness, the activity person will also step in covering tea / supper cook hours. A few of the care staff have a dual role and cover various areas as part of the contracted hours. The cook will prepare the tea and activity person/tea/ supper person will extend their hours to coverif needed.”Staff rotas showed there were at least 2 or 3 days each week when there was no catering support after 2pm. Care staff were allocated to complete this task, even though the number of care staff was reduced to 5 in the afternoon and evening, further reducing this as well. The registered manager used a dependency tool to calculate how many staff were needed. However, this had not considered the complex layout of the building or completing other tasks such as catering.

Staff told us there were not enough staff, this had also been mentioned in staff meetings and staff surveys. Staff meeting minutes showed staff had raised concerns that if night staff did not get enough people up, staff were still supporting people up until lunchtime, as the seniors were completed the medicines. There was no recognition by the registered manager staff were struggling.

We spent over 4 hours observing people’s experience in the communal lounges. People’s interaction with staff was limited and task orientated, many people were sat in the same position the whole time including those who were in the lounge when we arrived. The activities co-ordinator spent time with some people, but most people spent their time asleep or staring ahead of them. Some people did not receive their breakfast until 11.45am and the lunch time meal started at midday. There were not enough staff to support people to have a pleasant experience at lunchtime. People did not receive their meals at the same time and had to wait for long periods to be helped with their meals. Some people did not eat their meal as it was cold when offered to them. After an hour and a half people had still not received their pudding.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There were infection control audits had been completed by the housekeeping staff. The audits had identified issues such as damage floors, sink not working in the laundry and broken furniture, which had been identified in January 2025 and remained at time of our inspection. There was an action plan in place, but this did not have any timescales. During our inspection, we identified concerns including clinical waste bins not working, stained toilets and soiled rubbish not being removed from people’s rooms.

There were items of furniture which were stained and could not be cleaned effectively. There were dining chairs which had fabric seats that were not washable. The management team had covered them with thick plastic sheeting to resolve this, other furniture had been washed but remained stained.

Staff wore personal protective equipment (PPE) such as gloves and aprons when required to keep people safe. There were supplies of PPE available around the building.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not managed safely. The systems for recording medicines stock and administration were electronic and staff had received training in the system. We reviewed the records and stock of medicines, and we identified shortfalls in administration and checking by staff.

Some people were prescribed medicines which had additional recording requirements. One person was prescribed the medicine twice a day, the recording book showed there were 44 tablets left which was 7 more than there should be. Staff had counted the tablets confirming the number available matched the book, but they had not identified they had not been given as prescribed, and the actual number was more than there should be. The electronic record was not accurate as these records showed a balance of 40, staff had indicated the medicine had been given when it had not.

The medicine records were not always accurate and did not match the number of tablets available. The electronic system showed a person had received 56 Atrovastatin tablets, however, there were 28 missing from the stock. The deputy manager told us they thought there had been a mistake when the medicines were signed in, however, this could not be confirmed. Another person had not received all their medicines as prescribed as there was an additional tablet in the box, which had not been given.

Some people were prescribed medicines on a ‘when required’ basis such as for constipation or anxiety. There was guidance in place for staff, but this was not person centred. For example, a person was prescribed Cosmocol sachets 1-3 once or twice a day for constipation. There was no guidance about how many sachets should be given and how often, this placed the person at risk of receiving more medicine than they needed.

Staff received medicine training, and their competency was assessed before they could medicine. This was completed yearly or if an error had been identified. The registered manager told us they would increase their medicine audits following our findings.